Case Management Standard Client Intake
Ryan White Part B HIV Medical Case Management
Standard Client Intake Form
Client ID: _____________________ Case Manager: __________________________________________
Date: _____/_____/_________ Person Completing Form: ______________________________________
Demographics – Demographics screen in CAREWare
Legal first name: _______________________________________ Middle: ________
Legal last name: _______________________________________ Preferred name: ______________________
Date of birth: _____/_____/_________
|Sex at birth: | Male |
| |Female |
| |Intersexed |
SSN: _______________________________________
HIV status:
HIV-positive, not AIDS Date of HIV diagnosis: _____/_____/_________
HIV-positive, AIDS status unknown
CDC-defined AIDS Date of AIDS diagnosis: _____/_____/_________
Transmission category: (check all that apply)
Male who has Sex with Male(s) Heterosexual contact Blood transfusion/blood products
Injecting Drug Use Perinatal Transmission Other: Presumed heterosexual contact
Hemophilia/Coagulation Disorder Undetermined/Unknown Other: ________________________
Ethnicity: (choose one)
Non-Hispanic
Hispanic
| Mexican | Mexican-American | Chicano/a | Puerto Rican | Cuban | Other Hispanic or Latino/a |
Race: (check all that apply)
White
Black or African-American
American Indian or Alaska Native
Asian
| Asian Indian | Chinese | Filipino | Japanese | Korean | Vietnamese | Other Asian |
Native Hawaiian or Other Pacific Islander
| Native Hawaiian | Guamanian or Chamorro | Samoan | Other Pacific Islander |
Other
Other Demographics – Additional Info screen in CAREWare
Country of origin: ____________________________ Subculture/tribe: _____________________________
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